Racial disparity in baby death rates
Racial disparity in baby death rates is not a new subject. It's a complex, insiduous, and at times, inflammatory, issue. People are often reluctant to talk about it. I think that contributes to the problem. In my corner of the world, there are communities where the baby death rate is nearly three times the national norm. Virginia ranks in the lower half of the country on this health indicator, and southeastern Virginia has some of the worst rates in the commonwealth. The state recently kicked off some new efforts to tackle the problem, so I thought this would be a good time to examine the issue and put some human faces to a subject that many see only in statistics. As expected the reaction was vitriolic at times. It's easier to take on issues that have solutions that you can get your arms around, and that can be measured in months and years. It's more difficult to take on tough issues with solutions that are decades in the making. That doesn't mean we shouldn't take them on.
La' Tanya Pillow named her baby Nevaeh when she was born in February. It's "heaven" spelled backward, a nod to the joy Pillow felt when the girl was born wriggling with life at 5 pounds, 12 ounces.
Two other babies Pillow gave birth to died, one in 2005 and another in 2007 - both barely a pound, both four months early. The first boy was born still; the other died after a four-hour fight.
The death of a child is not uncommon in Pillow's world. A number of factors combine to make mothers like Pillow more likely than most to lose a baby.
For starters, she lives in Virginia, which ranks in the bottom half of the country for infant mortality.
And she lives in Norfolk, where rates between 2005 and 2009 were worse than the state average.
And she's black, a race that in this city had an infant mortality rate more than double that of whites.
Put the numbers together, and you find that black babies born in Norfolk have a death rate substantially larger than that of the country as a whole.
The insidious march of death often goes unnoticed - not just in pockets of poverty in Norfolk, but throughout the region. Babies who die in hospitals and apartments and homes from being too small or too young or too sick don't make headlines like people who die from guns and car accidents.
The first two babies born to La' Tanya and her husband, Deon, were part of that invisible wave, but their deaths also led to changes in La' Tanya's third pregnancy: A stitch in her cervix helped delay having the baby prematurely, and bed rest and two days in the hospital before the birth helped.
Those types of prevention are getting fresh attention in Virginia, which in 2009 had 740 babies die before their first birthday. That Virginia statistic is greater than the number of people who were slain and is nearly as large as the number of people who died in car accidents.
It's a number Virginia Health Commissioner Karen Remley is committed to bringing down.
Untangling one risk factor from another in the tapestry of infant mortality is impossible:
Poverty. Lack of education. Poor health practices. Sporadic access to health care. High rates of teen pregnancy and single parenthood.
Some recent national studies are showing that even when age, income and education are taken out of the equation, blacks still have higher rates of baby death than other races, a difference some attribute to generations of racism and stress.
"What we do know is if you are poor and uninsured and black, you have a much higher chance of losing your baby in the first year of life," Remley said. "We know that is a specific population that is at very high risk."
In 2007, then-Gov. Timothy M. Kaine distributed $1 million to 10 cities to find ways to reduce infant mortality. Half were in Hampton Roads, where one-third of the infant deaths in the state occurred in previous years, higher than you'd expect for the region's population base.
When Remley, a pediatrician who spent much of her career working in Hampton Roads, was appointed health commissioner in 2008, one of the first things she did was launch a statewide infant mortality task force.
At the table were members of AARP, to bring grandparents, who play a key role in baby-sitting and parent advising; the NAACP, to help with the high rates among blacks; and private doctors as well as public health ones.
Pieces of solutions were already in place, and the task force brought them together, looked at what works, what doesn't, what needed to be done, and bolstered the efforts.
A few examples of what's going on at the ground level:
- In Chesapeake, mapping statistics helped city health officials better target home-visiting and family planning efforts. Instead of looking at the issue solely from the woman's point of view, they have been trying to educate men. Nurse midwife Laurie Irwin-Pinkley, for instance, helped start a contraception outreach program in 2009 in four public housing projects, distributing condoms in small paper bags.
- This month, a program called "A Healthy Baby Begins with You" will begin at Norfolk State University. The national initiative aims to improve "preconception" health of the college-age black population by training minority students as health ambassadors.
- Home-visiting programs go by different names in different cities - Resource Mothers, Loving Steps, BabyCare, Healthy Start - and continue to show positive results, along with "Back to Sleep" campaigns to prevent sudden infant death syndrome, and free cribs so infants don't sleep with adults in beds.
- Forms will soon be distributed in emergency rooms throughout the state for women who have just tested positive for pregnancy so they can immediately apply for Medicaid.
- A new "text4baby" program sends free text messages to women at key milestones during their pregnancies and throughout their babies' first year of life.
Jacqueline Yetka works at the Eastern Virginia Perinatal Council, interviewing women whose babies have died to find out what might have contributed to the deaths.
One new emphasis that Yetka sees as critical is improving the health of women - not just when they're pregnant but before and after.
Poor dental care, for instance, can cause infections that might result in miscarriages or premature labor. Being overweight can lead to high blood pressure and diabetes, which also puts the baby at high risk of early birth. Smoking by pregnant women continues to pull down baby survival rates.
All those issues need to be addressed throughout life, not just when women are pregnant, which is when many low-income women qualify for Medicaid, the state-federal insurance for the poor.
"Some don't see the relevance of taking care of themselves, not just their reproductive health, but their health in general," Yetka said.
It's a big ship to turn, but officials feel they are making progress. Teen pregnancy rates are down, and an annual March of Dimes report released in November showed 11 percent of the state's babies were born prematurely, an improvement from the 12.3 percent reported two years earlier. Premature births are a risk factor for infant mortality.
It was still a grade of D, but only one point away from a C.
"It's the first time I've ever been happy about getting a D," Remley said.
One September evening, Keiana Watford and A.J. Williams arrived with their son, Ki'jon, at the Portsmouth Family Medicine office.
Rather than being ushered into an exam room, the couple sat on sofas and chairs in a lounge area with other families who also brought their babies. Family practice doctor Robert Ringler and nurse Laura Jordan started meeting with these women and their partners about a year ago in a "Centering Pregnancy" program.
The program, funded by the March of Dimes and coordinated by Eastern Virginia Medical School in Norfolk and the Portsmouth Health Department, is based on a national model that has been showing good results in improving the health of babies. The idea is to bring women out of exam rooms and into support groups.
When the mothers were each a few months into their pregnancies, they began meeting together with Ringler and Jordan. At first it was every four weeks, then more frequently as their due dates approached. Ringler examined them individually at the beginning of the class, then he and Jordan facilitated a group discussion that ran for two hours.
The mothers all delivered their babies this summer. Three agreed to keep meeting during their babies' first year, in the region's first "Centering Parenting" class.
The mothers are all single and in their teens or early 20s. Two brought their boyfriends with them; one brought her mother. All qualify for Medicaid.
They compared weights and birthdates of their children as they passed them around, cooing over each one and chatting about life with a newborn.
Ringler and Jordan followed a range of newborn-related topics:
Sleep schedules. How often the babies were feeding. Whether the parents were using contraception. How much they're interacting with their children.
"What's your favorite thing to do with your baby, Raven?" Ringler asked.
"I like to talk with her when I wake up," said Raven Greene, 18.
"The more you talk with your babies, the more emotional feedback they get," Ringler said. "If you're happy, they will feel that."
He asked where their babies sleep, and one mother mentioned letting her baby sleep with her in a bed.
"The biggest thing with that is it's dangerous because if you're a heavy sleeper, you can roll over on the baby," he said. "I've taken care of families where the baby's been smothered in bed. It's OK to cuddle the baby in bed if they're crying, but as soon as they stop, get them back in the bassinet."
"You sleep better, and they sleep better," Jordan added.
"Any one smoke in the house?" Ringler asked.
"Not in the house," said Williams, who said he only smokes outside since the baby was born.
"We're going to wear you down until you'll realize it's not worth it," Ringler said good-naturedly.
Ringler, who is an obstetrics director and assistant professor in the EVMS Department of Family and Community Medicine, said the approach requires letting the parents take ownership of the session's discussion. Ringler provides medical advice, but he's careful not to lecture.
"Anybody having any major housing issues, insurance issues?" he asked. "Anyone going through the baby blues?"
"I left him with him for two hours," Watford said about a recent time when she left Ki'jon with Williams. "At 11:30, he called me because Ki'jon was crying."
"No, it was 4," Williams said. "I tried everything. I walked with him, I swaddled him, some of that stuff doesn't work for him."
"Different things work on different days," Ringler said. "Don't give up. When three of them don't work, the other two might."
The approach encompasses not just the baby's well-being but also the health of the parents. Not just this baby, but the last one and the next one, so that parenting and health is planned and seamless, not happenstance and sporadic.
It's a constellation of issues that Dr. Michael Lu, an associate professor of obstetrics and public health at UCLA, has been examining for years in his study of racial disparity in infant mortality. He believes that the effects of racism over a lifetime, not just during the nine months of pregnancy, increase the risk of premature birth, which boosts infant death.
Stress or repeated infections can affect the immune system in ways that set the stage for poor health and too-tiny babies.
To improve birth outcomes, he says, a "life course" of good health is needed from the time children are born throughout adulthood.
One day in December, Williams was feeding Ki'jon, now 5 months old, in their Portsmouth apartment. Watford watched on as their older child, Asha, scampered through the apartment. Watford was 16 when she became pregnant with Asha, who is now 3.
That's not unusual in a city where the rate of teen pregnancy was more than twice that of the state rate in 2009.
The second time Watford got pregnant, she decided to try the Centering Pregnancy classes after someone from the health department told her about them.
"You could talk about anything, things you might not normally talk to a doctor about because you were too embarrassed," Watford said.
"I got dragged into it," joked Williams, 23.
But Williams said he learned a lot, which likely helped Ki'jon. A study released last year by the University of South Florida found that a father's involvement before his child is born helps prevent death during the first year of life, particularly among blacks.
During the pregnancy classes, Williams was often the only father there: "They made me feel comfortable and made me want to come back."
He also felt like he brought up issues from a father's perspective that helped others in the class. When Ki'jon was born, Williams was in the delivery room. He said Ringler not only helped him find ways to comfort Watford during labor, but "he gave me some videotaping tips, too."
Williams is looking for work, so he cares for Ki'jon while Watford works as a personal aide. He wants a job so they can buy a house and get married one day.
The young couple thinks about their friends and families, the babies who have died, and list the different things that contribute to stress:
Being too young. Not having the father involved. Not eating right. Not being ready. Worrying about the future.
"It's something that can be prevented in some cases," Watford said about the deaths of babies. "Unexpected pregnancies happen. I mean, I had one, but it's not something you should rush into. A baby is a big step and you need a support system... a mother and a father."
Coming tomorrow: Health disparities in two communities - one urban, one rural - lead to federally funded efforts to get people moving in Portsmouth and on the Eastern Shore.
Elizabeth Simpson, (757) 446-2635, email@example.com